Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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Copaxone

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Patient Access Network Foundation (PAN)

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Copaxone (glatiramer acetate)
 

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section and sign
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Updated July 10, 2015


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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Copaxone

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Copaxone Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: TEVA Pharmaceuticals

Shared Solutions
PO Box 7588Overland Park, KS 66207-0588

TEL: 800-887-8100


Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

 Copaxone Patient Assistance Program: Contact program

 

Medications

  • Copaxone syringe; prefilled (glatiramer acetate)
 

Eligibility Requirements   

Insurance Status Must not have public insurance, may have private insurance
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Not required
US Residency Required? Must be citizen
   

Application

Obtaining Call
Receiving Faxed, mailed or emailed
Returning Fax, mail or email
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Decision is mailed
Decision Timeframe 5-7 business days
   

Medication

Amount/Supply Up to a 30 or 90 day supply
Sent To Patient's home
Delivery Time Shipped overnight
Refill Process Patient must contact company
Limit Not specified
Re-application New application, new documentation yearly
   

Additional Information


Updated April 01, 2015


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3.
 

Copaxone

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Diplomat's Co-Pay Assistance Navigator Program

This is a copay assistance program.

Provided by: Diplomat Specialty Pharmacy

ATTN: FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507

TEL: 877-977-9118 ext. 89864


FAX: 810-282-0176
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Diplomat Request of Financial Assistance Form

 

Medications

  • Copaxone syringe; prefilled (glatiramer acetate)
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Yes
Income Determined case by case
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Yes
   

Application

Obtaining Call or complete online
Receiving Faxed, mailed or complete online
Returning Fax or mail
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section, sign and provide annual income information. Proof of income may be request by program at any time
Decision Communicated Patient and/or Doctor are notified
Decision Timeframe Within 1-2 business days
   

Medication

Amount/Supply Amount requested is sent
Sent To Patient's home
Delivery Time Once approved; within 2 business days
Refill Process Company contacts patient to arrange
Limit Varies per medication
Re-application Determined case by case
   

Additional Information

Diplomat Specialty Pharmacy is a full service pharmacy that can help patients seek funding assistance for the copay portion of their required medications. Applications can be completed online or Prescription, Demographics and Proof of Income may be faxed to 810-282-0176 Attn: Dorrie


Updated July 27, 2015